CHAPTER 17 - Radical Neck Dissection

Abstract

The history of the neck dissection for head and neck cancer stretches back nearly two centuries. Even in the early 19th century, physicians were aware of the poor prognosis associated with cervical metastases in head and neck cancer. Other surgeons had advocated for the removal of the lymphatic tissue of the neck, but it was Dr. George Crile’s 1906 article that described en bloc resection of the cervical lymph nodes for a clinically positive nodal disease that is credited with the first description of the technique. The procedure removed all lymph nodes in the lateral neck (now known as levels I-V) and the spinal accessory nerve (CN XI), internal jugular vein (IJV), sternocleidomastoid muscle (SCM) along with several other surrounding structures. However, this procedure resulted in significant cosmetic deformity and loss of function. Over time, the procedure has been modified to reduce morbidity while maintaining oncologic efficacy. The modified radical neck dissection, which advocated for the preservation of at least one of the critical non-lymphatic structures (CNXI, IJV, or SCM) was proposed by Drs. Bocca and Suarez independently in the 1960s.Studies detailing the lymphatic drainage pathways of various head and neck regions further altered the classical radical neck dissection allowing for dissection of limited lymph node basins of the neck based on tumor location. As anatomic and oncologic understanding has improved, the neck dissection has become increasingly narrow in scope. Prophylactic neck dissections are also utilized for any clinically negative head and neck tumor that has a greater than 20% chance of having occult metastasis to the neck.In 2002, the American Academy of Otolaryngology-Head and Neck Surgery proposed a standardized classification system for naming the various neck dissections in use which is still in use today. The radical neck dissection refers to the removal of levels I-V along with the SCM, IJV, and CN XI. The modified radical neck dissection also removes levels I-V but spares at least one non-lymphatic structure (SCM, IJV, or CN XI). The selective neck dissection refers to any procedure which removes one or more levels of the neck based on patterns of cervical metastasis. Finally, an extended neck dissection refers to any neck dissection that removes additional structures of lymph nodes from areas not addressed in radical neck dissection.